What is a balance disorder?
SThe bony labyrinth inside the ear is how you sense balance. Disorders of this organ lead to dizziness and vertigo, among other symptoms.
A balance disorder is a condition that makes you feel unsteady or
dizzy,
as if you are moving, spinning, or floating, even though you are standing
still or lying down. Balance disorders can be caused by certain health
conditions, medications, or a problem in the inner ear or the brain.
Our sense of balance is primarily controlled by a maze-like structure in
our inner ear called the labyrinth, which is made of bone and soft tissue.
At one end of the labyrinth is an intricate system of loops and pouches
called the semicircular canals and the otolithic organs, which help us
maintain our balance. At the other end is a snail-shaped organ called the
cochlea, which enables us to hear. The medical term for all of the parts of
the inner ear involved with balance is the vestibular system.
Hearing and Balance Anatomy
Medical Author: Benjamin C. Wedro, MD,
FACEP, FAAEM
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR
The anatomy of the ear can be a little confusing, especially since the ear is
responsible not only for hearing, but also for balance.
There are three components to the ear: the outer ear, the middle ear and the
inner ear. All three are involved in hearing but only the inner ear is
responsible for balance.
The outer ear is composed of the pinna, or ear lobe, and the external
auditory canal. Both structures funnel sound waves towards the ear drum or
tympanic membrane allowing it to vibrate. The pinna is also responsible for
protecting the ear drum from damage. Modified sweat glands in the ear canal form
ear wax.
The middle ear is an air filled space located in the temporal bone of the
skull. Air pressure is equalized in this space via the Eustachian tube which
drains into the nasopharynx or the back of the throat and nose. There are three
small bones, or ossicles, that are located adjacent to the tympanic membrane.
The malleus, incus, and stapes are attached like a chain to the tympanic membrane
and convert sound waves that vibrate the membrane into mechanical vibrations of
the three bones. The stapes fills the oval window which is the connection to the
inner ear.
Learn more about hearing and balance »
How does the vestibular system work?
Our vestibular system works with other sensorimotor systems in the body,
such as our visual system (eyes) and skeletal system (bones and joints), to
check and maintain the position of our body at rest or in motion. It also
helps us maintain a steady focus on objects even though the position of our
body changes. The vestibular system does this by detecting mechanical
forces, including gravity, that act upon our vestibular organs when we move.
Two sections of the labyrinth help us accomplish these tasks: the
semicircular canals and the otolithic organs.
The semicircular canals are three fluid-filled loops arranged roughly at
right angles to each other. They tell the brain when our head moves in a
rotating or circular way, such as when we nod our head up and down or look
from right to left.
Each semicircular canal has a plump base, which contains a
raindrop-shaped structure filled with a gel-like substance.
This structure, called the cupula, sits on top of a cluster of sensory
cells, called hair cells. The hair cells have long threadlike extensions,
called stereocilia, that extend into the gel. When the head moves, fluid
inside the semicircular canal moves. This motion causes the cupula to bend
and the stereocilia within it to tilt to one side. The tilting action
creates a signal that travels to the brain to tell it the movement and
position of your head.
Between the semicircular canals and the cochlea lie the otolithic organs,
which are two fluid-filled pouches called the utricle and the saccule. These
organs tell the brain when our body is moving in a straight line, such as
when we stand up or ride in a car or on a bike. They also tell the brain the
position of our head with respect to gravity, such as whether we are sitting
up, leaning back, or lying down.
Like the semicircular canals, the utricle and the saccule have sensory
hair cells. These hair cells line the bottom of each pouch, and their
stereocilia extend into an overlying gel-like layer. On top of the gel are
tiny grains made of
calcium carbonate called otoconia. When you tilt your
head, gravity pulls on the grains, which then move the stereocilia. As with
the semicircular canals, this movement creates a signal that tells the brain
the head’s position.
Our visual system works with our vestibular system to keep objects from
blurring when our head moves and to keep us aware of our position when we
walk or when we ride in a vehicle. Sensory receptors in our joints and
muscles also help us maintain our balance when we stand still or walk. The
brain receives, interprets, and processes the information from these systems
to control our balance.
Figure 1. Diagram of outer, middle, and inner ear. The outer ear is labeled
in the figure and includes the ear canal. The middle ear includes the eardrum
(tympanic membrane) and three tiny bones for hearing. The bones are called the
hammer (malleus), anvil (incus), and stirrup (stapes) to reflect their shapes.
The middle ear connects to the back of the throat by the Eustachian tube. The
inner ear (labyrinth) contains the semicircular canals and vestibule for
balance, and the cochlea for hearing.
The vestibular structures of the inner ear are the vestibule (which is made
up of the utricle and saccule) and the three semicircular canals. These
structures work somewhat like a carpenter’s level (a tool used to show how “level”
a horizontal or vertical surface is). That is, they work by way of the
vestibulocochlear nerve with the vestibular center in the brain to deal with
body balance and position. (The rest of the inner ear, that is, the cochlea, is
concerned with hearing.) Thus, the vestibular system includes the vestibule, the
semicircular canals, the vestibular branch of the vestibulocochlear nerve, and
the vestibular center in the brain.
The vestibular system measures linear and rotational movement. A number of
disorders can cause this system to stop working or provide inappropriate
information. These disorders include
Ménière syndrome,
labyrinthitis,
benign
paroxysmal positional vertigo,
ear infections,
tumors, or trauma. Each of these
conditions is discussed below.
QUESTION
What is vertigo?
See Answer
What are the symptoms of a balance disorder?
If your balance is impaired, you may feel as if the room is spinning. You
may stagger when you try to walk or teeter or fall when you try to stand up.
Some of the symptoms you might experience are:
- Dizziness or
vertigo (a spinning sensation) - Falling or feeling as if you are going to fall
- Lightheadedness, faintness, or a floating sensation
- Blurred vision
- Confusion or disorientation
Other symptoms are nausea and vomiting, diarrhea, changes in heart rate
and blood pressure, and fear, anxiety, or
panic. Some people also feel
tired, depressed, or unable to concentrate. Symptoms may come and go over
short time periods or last for longer periods of time.
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What causes a balance disorder?
A balance disorder may be caused by viral or bacterial infections in the
ear, a head injury, or blood circulation disorders that affect the inner ear
or brain. Many people experience problems with their sense of balance as
they get older. Balance problems and dizziness also can result from taking
certain medications.
In addition, problems in the visual and skeletal systems and the nervous
and circulatory systems can be the source of some posture and balance
problems. A circulatory system disorder, such as low blood pressure, can
lead to a feeling of dizziness when we suddenly stand up. Problems in the
skeletal or visual systems, such as arthritis or eye muscle imbalance, also
may cause balance problems. However, many balance disorders can begin all of
a sudden and with no obvious cause.
What are some types of balance disorders?
There are more than a dozen different balance disorders. Some of the most
common are:
Benign paroxysmal positional vertigo (BPPV) or positional vertigo is a
brief, intense episode of vertigo that occurs because of a specific change
in the position of the head. If you have BPPV, you might feel as if you’re
spinning when you look for an object on a high or low shelf or turn your
head to look over your shoulder (such as when you back up your car). You
also may experience BPPV when you roll over in bed. BPPV is caused when
otoconia tumble from the utricle into one of the semicircular canals and
weigh on the cupula. The cupula can’t tilt properly and sends conflicting
messages to the brain about the position of the head, causing vertigo. BPPV
sometimes may result from a head injury or just from getting older.
Labyrinthitis is an infection or inflammation of the inner ear that
causes dizziness and loss of balance. It frequently is associated with an
upper respiratory infection such as the flu.
Ménière’s disease is associated with a change in fluid volume within
parts of the labyrinth. Ménière’s disease causes episodes of vertigo,
irregular hearing loss,
tinnitus (a
ringing or buzzing in the ear), and a feeling of fullness in the ear. The
cause of this disease is unknown.
Vestibular neuronitis is an inflammation of the vestibular nerve and may
be caused by a virus. Its primary symptom is vertigo.
Perilymph fistula is a leakage of inner ear fluid into the middle ear. It
can occur after a head injury, drastic changes in atmospheric pressure (such
as when scuba diving), physical exertion, ear surgery, or
chronic ear
infections. Its most notable symptom, besides dizziness and nausea, is
unsteadiness when walking or standing that increases with activity and
decreases with rest. Some babies may be born with perilymph fistula, usually
in association with hearing loss that is present at birth.
Mal de debarquement syndrome (MdDS) is a balance disorder in which you
feel as if you’re continuously rocking or bobbing. It generally happens
after an ocean cruise or other sea travel. Usually, the symptoms will go
away in a matter of hours or days after you reach land. However, severe
cases can last months or even years.
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How is a balance disorder diagnosed?
Diagnosis of a balance disorder is difficult. There are many potential
causes – including medical conditions and medications.
To help evaluate a balance problem, your doctor may suggest you see an
otolaryngologist. An otolaryngologist is a physician and surgeon who
specializes in the ear, nose, and throat. An otolaryngologist may request
tests to assess the cause and extent of the balance problem depending on
your symptoms and health status.
The otolaryngologist may request a hearing examination, blood tests, an
electronystagmogram (which measures eye movements and the muscles that
control them), or imaging studies of your head and brain. Another possible
test is called posturography. For this test, you stand on a special movable
platform in front of a patterned screen. The doctor measures how your body
moves in response to movement of the platform, the patterned screen, or
both.
How is a balance disorder treated?
The first thing a doctor will do to treat a balance disorder is determine
if your dizziness is caused by a medical condition or medication. If it is,
your doctor will treat the condition or suggest a different medication.
Your doctor also may describe ways for you to handle daily activities
that increase the risk of falling and injury, such as driving, walking up or
down stairs, and using the bathroom. If you have BPPV, your doctor might
prescribe a series of simple movements, called the Epley maneuver, to help
dislodge the otoconia from the semicircular canal. You begin the Epley
maneuver by sitting upright, with the help of a trained therapist, then
quickly lie down on your back, turn your head to one side, and wait for a
minute or two before sitting back up again (see Figure 3). For some people,
one session will be all that is needed. Others might need to repeat the
procedure several times at home to relieve their dizziness.
If you are diagnosed with Ménière’s disease, your doctor may recommend
changes in your diet, such as reducing the use of salt in your food and
limiting alcohol and caffeine. Not smoking also may help. Some anti-vertigo
or anti-nausea medications may relieve your symptoms, but they can also make
you drowsy. Other medications, such as the antibiotic gentamicin or
corticosteroids, may be injected behind the eardrum to reach the inner ear.
Although gentamicin helps reduce dizziness, it occasionally destroys sensory
cells in the cochlea and causes permanent hearing loss. The risk of hearing
loss can be lowered if small doses of gentamicin are given off and on until
your symptoms decrease. Corticosteroids don’t cause hearing loss; however,
research is underway to determine if they are as effective as gentamicin.
Surgery on the vestibular organ may be necessary if you have a severe case
of Ménière’s disease.
Some people with a balance disorder may not be able to fully relieve
their dizziness and will have to develop ways to cope with it on a daily
basis. A vestibular rehabilitation therapist can help by developing an
individualized treatment plan that combines head, body, and eye exercises to
decrease dizziness and nausea.
To reduce your risk of injury from dizziness, avoid walking in the dark.
You also should wear low-heeled shoes or walking shoes outdoors and use a
cane or walker if necessary. If you have handrails in the home, inspect them
periodically to make sure they are safe and secure. Modifications to
bathroom fixtures can make them safer. Conditions at work may need to be
modified or restricted, at least temporarily. Driving a car may be
especially hazardous. Ask your doctor’s opinion about whether it’s safe for
you to drive.
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How do I know if I have a balance disorder?
Everyone has a dizzy spell now and then, but the term “dizziness” may
mean something different to different people. For some people, dizziness
might be a fleeting sensation of spinning, while for others it’s intense and
lasts a long time. Experts believe that more than four out of 10 Americans
will experience an episode of dizziness significant enough to send them to a
doctor.
To help you decide whether or not you should seek medical help for a
dizzy spell, ask yourself the following questions. If you answer “yes” to
any of these questions, talk to your doctor.
- Do I feel unsteady?
- Do I feel as if the room is spinning around me?
- Do I feel as if I’m moving when I know I’m sitting or standing still?
- Do I lose my balance and fall?
- Do I feel as if I’m falling?
- Do I feel “lightheaded” or as if I might faint?
- Do I have blurred vision?
- Do I ever feel disoriented, such as losing my sense of time or where I
am?
How can I help my doctor make a diagnosis?
You can help your doctor make a diagnosis and determine a treatment plan
by answering the questions below. Be prepared to discuss this information
during your appointment.
1. The best way I can describe my dizziness or balance problem is:
2. How often do I feel dizzy or have trouble keeping my balance?
3. Have I ever fallen? (When did I fall?)
- Under what conditions did I fall?
- How often have I fallen?
4. These are the medicines I take:
- (Include prescription medications and over-the-counter medicine, such as
aspirin, antihistamines, or
sleep aids.)
Name of medicine:
- How much (milligrams) and how often (times) per day:
- The condition I take this medicine for is:
Name of medicine:
- How much (milligrams) and how often (times) per day:
- The condition I take this medicine for is:
Name of medicine:
- How much (milligrams) and how often (times) per day:
- The condition I take this medicine for is:
At your appointment, take a minute to write down any instructions your
doctor has given you. Be sure to ask any questions you have before you leave
the office.
What research is being done for balance disorders?
BPPV is the most common balance disorder. Because the source of the
problem—displaced otoconia—is located deep within the ear, doctors have had
to rely mainly on observation and a medical history to make a diagnosis.
Researchers supported by the National Institute on Deafness and Other
Communication Disorders (NIDCD) now have created a head-mounted apparatus
that uses 3-D animation to map the location of otoconia in the inner ear.
The apparatus is built around a pair of infrared video goggles that gather
data from eye and head movements and then sends it to a computer program for
mapping. A second computer program uses the data to develop a step-by-step
guide for repositioning maneuvers to dislodge the otoconia from the
semicircular canals. If shown to be effective in clinical trials, the
apparatus and its software programs will help doctors more accurately
diagnose BPPV and guide repositioning maneuvers to ensure the best possible
treatment.
Other NIDCD-supported scientists are looking at the molecular mechanisms
that regulate the development of the inner ear. One research team has
identified a gene that encodes a protein that helps in the formation of the
semicircular canals and their related sensory tissue. Another team has
identified a family of genes, called the otopetrins, which help form
otoconia in mice. Findings from the mouse study could help researchers
determine if otoconia destroyed by aging, medications, infections, or trauma
can someday be regenerated in humans with balance problems.
NIDCD-supported scientists also are experimenting with several types of
vestibular prostheses, or replacement parts, in balance-impaired animals.
Researchers hope these devices will one day be used to compensate for
vestibular system loss in people.
One prosthesis uses a head-mounted motion sensor to mimic the ear and
brain’s natural signaling system. The sensor measures the head’s rotation
and sends the information to a microprocessor. The microprocessor then
converts the signals into electrical impulses and sends them to an electrode
implanted in the ear. The electrode stimulates the vestibular nerve,
creating a signal that helps the brain move the eyes to compensate for the
head’s rotation.
A second prosthesis is designed to simulate the movement of fluid within
the semicircular canal. In a normal ear, fluid changes help the brain
understand the movement and position of the head. The device combines
microcontroller circuitry with a tiny mechanical device that increases
normal fluid movement to provide a stronger vestibular signal to the brain.
Researchers also are studying the effectiveness of different types of
rehabilitative exercises as a treatment option for balance disorders. In one
NIDCD-funded study, researchers have used virtual reality technology to
simulate the aisles of a grocery store. Using a real cart attached to a
custom-built treadmill in front of a projection screen, patients “walk” down
aisles, scanning virtual store shelves for items on their list. Researchers
are testing whether practicing in the virtual store will lessen episodes of
dizziness in the real world, especially in visually complex environments.